Case Study

Medway Community Healthcare is a £57 million business with 1,250 staff providing a wide range of health and social care in local settings such as clinics, inpatient units and people’s homes. In 2011 Medway Community Healthcare (MCH) became a social enterprise Community Interest Company (CIC), providing community NHS services to the people of Medway. They were formed from the services directly provided by the then PCT and have a strong history of partnership working with local GPs, the acute and mental health trusts, as well as local authorities, the voluntary sector and other local stakeholders. MCH is an employee owned organisation with all staff having the opportunity to become shareholders.

Becoming a social enterprise was a significant opportunity for MCH, and for the local community. As an organisation that provides a range of high quality services across Kent and Medway, their vision is to continue to deliver high quality services whilst delivering excellent clinical outcomes for patients and maintaining our financial sustainability.

As a social enterprise, MCH believes it is vital that they have a shared understanding of the values needed to underpin everything they do. To help achieve this, in consultation with staff and stakeholders, they have developed organisational values which encompass being caring and compassionate, delivering quality and value, and working in partnership. Their values have been agreed by the board and form the basis for ensuring that everyone in the organisation adopts and works to the same shared behaviours.

1.Innovation  – led by and delivered by the service themselves

2.Leadership  – the service manager worked with colleagues from across and outside the organisation through a structured approach ensuring engagement, communication, feedback and delivery.

3.Outcomes  – the success of the project is shown in the feedback from people using the service ; 99% recommend the service, improved staff morale; vastly reduced waiting times, improved access, easier journeys and access to free parking. The ability to attend follow-on classes to maintain and continue improvements.

4.Sustainability  – the last year has shown the sustainability and enabled continued developments and access to unique and varied treatment, previously unavailable.

5.Transferability & Dissemination  – the learning has been celebrated across MCH, in whole or part the methodology has been utilised.

Since the mid-1980s, outpatient physiotherapy was based at the local acute hospital. In the last few years multiple problems were highlighted through patient feedback, causing the services satisfaction scores to reduce considerably to 60%.

There was poor road access to the hospital, which also suffers from pressure on parking, and patients were often having to wait up to one hour to find a space in which to park. Patients were also unhappy that they had to pay a minimum of �2 to park at the hospital. This, more often than not, resulted in patients arriving late for their appointments or even missing them completely.

There was a lack of continuity of care and clinicians were consistently running late across the day to try to accommodate those who were late due to the access issues. As a result of this the average waiting time for a routine patient rose 25 weeks and for urgent patients it was 4 weeks, which was considerably longer than is clinically or contractually indicated.

The service clinical area at the hospital had poor patient facilities, the environment consistently failed infection control and cleaning audits, there was ageing equipment and inadequate and poorly cleaned toilet facilities.

All of these issues resulted in the service reporting poor staff satisfaction and frustration at the helplessness of the service to improve things, despite support of senior managers. Reception staff consistently had to deal with the frustration and anger of the people who had been trying to access the service, which led to a high turnover and high sickness levels. There was lip service paid to engagement from the hospital trust and despite years of discussions, meetings and project plans, things were not seen to improve.

The Physiotherapy Team worked in partnership with the patient experience team to seek the views of the people using the service and staff working in the service to identify the issues the service faced � the service patient satisfaction rating (pre FFT) was very poor and yet most people described being very happy with the service they received and the outcomes of the treatments.

Working together the service and patient experience team developed a number of bespoke surveys including patient journey. A patient journey is a tool used to demonstrate where along the pathway the person feels the issues that led to a poor experience were. The service received lots of feedback, in part because people wanted to demonstrate that they valued the service once they actually got to it!

Most patients identified being frustrated before they reached the physiotherapist � reasons varied but included one or more of the following: waiting times, car parking costs and challenges, building access and appointment times. The service spoke to service users and other stakeholders (eg GPs and Consultants) as well as our commissioners to achieve a solution.

In 2013 the decision was made to provide the physiotherapy service in a purpose built facility at MCH house. Being a social enterprise has allowed this to be funded and the move to happen in a timely way. A change in contracting, from a block system to an Any Qualified Provider (AQP) system, enabled us to invest in additional staff to reduce the waiting list and meet the increasing demand. The MCH House Physio department now has:

• Free on- and off-site parking
• Purposely adapted new facilities including a gymnasium, six individual treatment rooms and eleven cubicles
• State of the art equipment � MCH invested in new equipment in order to maximise the potential for rehabilitation in people using the service
• Waiting lists reduced to under one week for all categories of people referred to the service, with a good range of follow-up appointments
• The ability to offer a wide range of appointment times � now able to offer appointments from 7am (when the building opens) until 8pm, including some weekend provision (previously opening times had to fit around security at the acute hospital)
• Greater control of the facilities � able to run classes to meet people�s needs, e.g. pilates, rather than trying to fit into unsuitable environments or around other service�s needs
• Developed clinical specialisms to meet the needs of the local population, including a new pelvic health service catering for male and female continence issues
• The ability to recruit people into research studies � taking part in national portfolio studies including low back pain, post-surgical knee and non-medical prescribing both independently and in collaboration with a neighbouring trust
• Investment in new treatment techniques and associated clinical education, with 90% outpatient staff trained in acupuncture, and a shockwave machine for recalcitrant tendinopathy.
• Telephone triage for all people referred into the service, within the first three days of receiving the referral. This has resulted in more accurate triaging, earlier implementation of advice and more accurate screening to ensure the clinician with the right skills is seen first time

These have all resulted in improved reputation and high patient satisfaction scores: 88% in 2013/2014 and currently 99%. MCH continues to collect high volumes of data relating to patient outcomes and satisfaction, which are all very positive.

Staff dedication, enthusiasm and buy-in

The service was highly motivated to improve patient experience, reduce waiting times etc. This has all contributed to their working life improving. The poor feedback and angry patients attending the department (due to poor access and waiting times) were causing the team to be demoralised. They worked tirelessly to reduce the waiting times and happily saw new patients in every gap they had. They worked to support new and temporary staff to ensure that patient experience remained high regardless of who delivered the care.

Working in a building/environment which is fit for purpose and provides everything people need for an outpatient musculoskeletal service

The investment from MCH and commissioners was invaluable to ensure people received the care they needed and deserved. They have received support for all their initiatives and plans to develop the service. Clear business plans enabled the executive team and board to see the benefits that training and staff development would have in terms of patient experience, outcomes of care for people and AQP income generation.

MCH is now the main provider of choice in the local area, and are now able to offer a fully flexible service across multiple sites in the area, offering early morning, evening and weekend appointments. Plus they are recognised as a flexible and responsive employer, all staff work flexible working patterns to meet the needs of the patients and the staff themselves. This is possible because MCH control their own estates.

•  – You will need clear project plans, timelines and trajectories.
•  – Open communication channels between the service, commissioners and board � everyone needs to understand the situation and the progress against plan
•  – Encouraging staff involvement every step of the way; the greater the understanding, the greater the motivation and more staff feel empowered and able to influence and manage change.
•  – MCH undertook a complete diary restructure based on future contracting intentions regarding appointment times and first to follow up ratios. This enabled the team to transition seamlessly into the new AQP contract, manage the expectations of people using the service, and those of the staff, and created a greater reliance on self-management and empowerment of the people the service was designed for.
•  – The use of blitz clinics; full day clinics involving all staff at both our main base and in outreach clinics. Patients were invited to attend during time blocks and were seen in turn. This helped to validate the waiting lists and see large volumes of new people being referred. We ensured all self-management material, appropriate orthotics etc were available to ensure everyone received an assessment and treatment at that contact. The lack of set times meant that people could be seen for the amount of time they needed, allowing a bespoke assessment to be carried out.
•  – The staff were rewarded with a Dominos pizza lunch provided by MCH;  this helped them to feel valued and fuelled them through the afternoon!

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